Thursday, October 27, 2016

Physical Therapy and Down Syndrome

Did you know that October is Down Syndrome Awareness and Acceptance Month? There's no better way to end the month of October with my last blog post of this month focusing on how physical therapy can benefit kiddos with Down Syndrome.

Karyotype of a female with Trisomy 21 (NDSS 2012)

So what exactly is Down Syndrome? It's actually a genetic condition where there is an extra chromosome, located on chromosome 21. This is why you may have also heard of Down Syndrome being called "Trisomy 21," as there are 3 chromosomes located on 21 instead of 2. According to the National Down Syndrome Society, the incidence of Down Syndromes is 1 in every 691 children, and it affects all people of all racial and economic backgrounds.

Every child is unique, therefore every child presents differently. However, some of the classic musculoskeletal signs of Down Syndrome that tend to affect their gross motor development includes poor muscle tone (hypotonia), loose joints (ligamentous laxity), and atlanto-axial instability (AAI).

AAI is excessive movement of the top 2 vertebrae in your spine, which can lead to subluxation. While most kiddos may not show any symptoms, neurological symptoms can occur such as intermittent or progressive weakness, changes in gait pattern or loss of motor skills, loss of bowel or bladder control, increased muscle tone in the legs, or changes in sensation in the hands and feet. Young kiddos with Down Syndrome should get an x-ray and be screened when they're around pre-school age, as screening before that age may be confusing because the bony structures may not show up clearly. High risk activities that should be avoided include tumbling, diving, swimming the butterfly stroke, and collision sports (NDSC 1991).

When working with any kiddo, you have to find their areas of strength and areas of difficulty. Areas of strength for children with Down Syndrome include social skills, learning through visual support, and reading words. These kiddos are some of the most friendly kiddos you'll ever encounter, which make it so much fun to work with them! They enjoy being around people and are very affectionate. Using demonstration, pictures, or gestures are great ways to use visual support to help them learn. 
Some areas of difficulty include motor development, communication, and memory. Their fine and gross motor development may be delayed. Expressive language, including speech clarity and grammar, may be a challenge.

The goals of PT for these kiddos are not necessarily to accelerate the development of a gross motor skill, but to minimize the development of compensatory movement patterns. (Winders 2001). Due to their low muscle tone and their loose joints, many of them often figure out other ways to access their environment. As physical therapists, we want to facilitate a life long love for movement! By teaching them correct movement patterns, we can minimize future injury, improve their strength and balance, so they can access their environment in the best way they can!


According to Patricia Winders, PT, Physical Therapy services should:
  • Be concerned with the kiddo's long-term function
  • Seek to minimize the development of compensatory movement patterns
  • Be based on a thorough understanding of the compensatory movement patterns that children with Down Syndrome are prone to developing
  • Be strategically designed to build strength in the appropriate muscle groups so that they will develop optimal movement patterns
  • Focus on gait, posture and exercise.

Winders wrote a chapter in the book Down Syndrome: What You CAN DO, titled "The goal and opportunity of physical therapy for children with Down syndrome." Winders came up with strategies in working with children with Down Syndrome, which I have found beneficial in my practice. Here are some strategies to use when you are working with these kiddos:


  • Decreased ability to generalize. This means that a skill learned in one setting does not necessarily transfer to another setting. For instance, they may do an awesome job climbing the stairs at home, but when confronted with stairs elsewhere, they may regress to a more primitive stair-climbing strategy until they have relearned the skill in the new setting.
  • Deliver information in small bite-sized pieces. If a child appears to have plateaued with a skill, the problem is most likely because the next piece of information is too large and needs to be further broken down.
  • Structure, consistency and a familiar environment. This is so important if you hope to get the best performance. Do not try something new or challenging when the child is tired, hungry or not at his best for some reason. Minimize distractions for the environment. Remember, quality over quantity!
  • Follow the child's lead. They must be motivated to perform a particular skill. Try to model your style of interaction after the parents' style, since it is familiar to the child and most likely to be successful.
  • Know when to quit. Some will only give you two repetitions at a particular skill and then insist on moving on. Other children will gladly give you a dozen repetitions. Set up the game so that the child is successful and avoid frustration!
  • Be strategic in planning your session. Practice what the child is ready to learn. Tackle the most difficult skills first before the child becomes tired. Alternate difficult tasks with easier ones to give the child time to recover their strength.
  • Be strategic in providing support. Children with Down Syndrome may become quickly dependent on support. Provide as little support as possible while still allowing the child success and remove the support as soon as possible.
  • Skills will be learned grossly at first and then refined. For example, children will initially learn to walk with a wide base and their feet externally rotated. While not an optimal gait pattern, it needs to be allowed initially and then refined through the post-walking skills. 
  • Do not interfere with an established skill in which the child has achieved independence. You will not be successful in introducing change and the child will only experience you as nagging. Change will need to be made at the next level of motor development. For instance, some children, instead of learning to creep on both kn earn to creep on one knee and one foot. Once this pattern has been established and the child is proficient in its use, you will not be successful in altering it and will succeed only in angering the child. Teach the child to use both knees in climbing up stairs rather than interfering with the established pattern.
I hope you found this informative and useful! Please feel free to comment with any questions or concerns you may have!

References
  • National Down Syndrome Society (NDSS) (2012). What is Down Syndrome? Retrieved from: http: //www.ndss.org/Down-Syndrome/ What-Is-Down-Syndrome/ 
  • NDSC Statement On: Atlanto-axial Instability (1991). Position Statement on Atlanto-Axial Instability. Retrieved from: http://www.ndsccenter.org/wp-content/uploads/AtlantoAxial_Instability.pdf
  • Winders, P.C. (2001). The goal and opportunity of physical therapy for children with Down syndrome. Down Syndrome Quarterly, 6(2), 1-5.
  • Yoon, L. (2015). Down Syndrome [Powerpoint slides]. Retrieved from Columbia University Program in Physical Therapy.
DISCLAIMER: "The San Diego Pediatric PT" claims no credit for any images posted on this site unless otherwise noted. Images on this blog are copyright to its respectful owners. If there is an image appearing on this blog that belongs to you and do not wish for it appear on this site, please contact me via e-mail at veronicaglendpt@gmail.com with a link to said image and it will be promptly removed.

Monday, October 24, 2016

Fun Activities with Bean Bags!

Here's a list of awesome ways that the therapists in the Pediatric Physical Therapists Facebook group use bean bags to work on balance, strength, coordination, and more!

- Sit or walk with them on your head to work on good posture!
Image result for bean bag activitiesWalking while balancing a bean bag on his head

- Not only are they good for learning how to throw, but they are also good for learning how to catch - they don't bounce out and they give deeper input! 


- Crab walk and have to keep them on their belly! You can also place bean bags on cones and have them crab walk and kick them off cones!


- Cross midline to put them from floor to a bucket on their other side!

Crossing the midline with a bean bag toss

- Put them on the top of the feet to work on heel walking, and don't let them fall off! Great activity for our toe walkers to strengthen the ankle dorsiflexors and promote posterior weight shifting!
- Creeping with them on the back and then "dump truck" them off by going into tall kneel!

- Pick them up with toes to place in a bucket - you can do this either in sitting or standing to work on single leg stance!

- Place them on the ground near the balance beam, have them sidestep across the beam, and when they come across the bean bag, they have to squat down to pick it up and maintain balance - Good for posterior weight shifting too for kiddos that toe walk and are too anterior!

- Hold it between their ear and shoulder and carry it to a target to work on active sidebending - great for older kids with torticollis!

- Have them standing on a dynadysc or balance board and toss them to you as you move around them to practice throwing to a target, trunk rotation and standing dynamic balance! 

- To make crunches fun! Have them lay on their back over a Swiss ball, grab a bean bag and use core strength to sit up so they can throw them in a bucket!

- Throw them while doing tall kneel/half kneel on a swing!

- Bear walk and use foot or hand to knock them off top of cones!

- Place them under a yoga mat at all different spots to make uneven terrain!

DISCLAIMER: "The San Diego Pediatric PT" claims no credit for any images posted on this site unless otherwise noted. Images on this blog are copyright to its respectful owners. If there is an image appearing on this blog that belongs to you and do not wish for it appear on this site, please contact me via e-mail at veronicaglendpt@gmail.com with a link to said image and it will be promptly removed.

Friday, October 21, 2016

Fun Activities with Hula Hoops!

Growing up dancing Hula and Tahitian, no toy was more fun to show off to my friends than the hula hoop! Here are other ways that the therapists in the Pediatric Physical Therapists group use a hula hoop to work on strength, balance, and reaching those gross motor milestones!
  • Jump in/out to work on jumping forward and over obstacles - easy clean up hop scotch! 
              
  • Hold them vertically and have kids step in and out - great way to work on single leg balance and body awareness!
  • Jump Rope with the Hula Hoop! - talk about coordination!
  • Have them catch the hoop - have the kiddo stand beside you, roll it down a long hall to see if they can catch up to it and stop it. You can also play "catch" by rolling it back and forth between you and the kiddo! 
  • Roll the hula hoop while they try to jump/crawl through on the run - great for projected action sequences for higher level kiddos! 
  • For kids learning to walk, have them hold onto an end while you hold onto other end. You can also use this to practice walking backwards too!
  • Use it as a target for throwing bean bags!
  • Crab walk across a pathway of vertical hoops without touching their feet or hands on them - added challenge to the basic crab walk!
  • Use a hula hoop as a place marker - good for teaching ball skills! Have them stand inside the hula hoop so they don't walk closer to the target!
  • Place at the bottom of the stairs as a "puddle" to jump into
  • Have them pull you on scooterboard while you both hold onto the hula hoop - or vice versa!
  • Hold on to hoop while kneeling on airex pad or rocker board to play "tug of war!
  • Use one in the center and ones all around like a flower and have them jump forward and sideways in a flower pattern coming back to center each time!
  • If you have other kiddos around, make a large circle with all of them holding onto the hula hoop and if when you say freeze they have to stand on 1 foot
  • Use both hands to pick them up and to to put over large cones to work on bilateral coordination
  • Step in/out to work on single leg balance and safety awareness!
  • Remember the game Skip-It? Use the hula hoop spinning it around 1 ankle while hopping over it with the other!
  • Use them in an obstacle courses - either place them at a certain distance to jump into, or hop or stand on one foot in them!
Comment on this post if you have any other creative activities!

DISCLAIMER: "The San Diego Pediatric PT" claims no credit for any images posted on this site unless otherwise noted. Images on this blog are copyright to its respectful owners. If there is an image appearing on this blog that belongs to you and do not wish for it appear on this site, please contact me via e-mail at veronicaglendpt@gmail.com with a link to said image and it will be promptly removed.

Monday, October 17, 2016

Fun Activities with a Yoga Mat!

Yoga mats are a great tool to use not just for yoga, but for therapeutic activities as well! Here is the list compiled by the Pediatrics Physical Therapy Facebook group of fun activities you can do using yoga mats!

  • Easy DIY traveling hopscotch - great for jumping practice!



  • Hamstring Stretch - roll part of the yoga mat to help those kiddos who have trouble getting a full hamstring stretch!



  • Use a mat to work on maintaining a straight path for target practice! 



  • Balance practice - an easy clean up balance beam, great for practicing tandem stance on a rolled up mat! 



  • Use a rolled up yoga mat placed horizontally tapped down with painters tape for stepping on top and down or over! 



  • Rolled up yoga mat with heels on ground and toes on mat - great for our toe walkers who need a passive calf stretch in standing!



  • Roll or scrunch up a mat to use to support babies into quadruped!



  • To practice walking or crawling over uneven surfaces, place pillows, surfboards, large bubble wrap, etc underneath the yoga mat! Add a tunnel over this surface for an additional crawling challenge!



  • Use tape to place lines for jumping with measured out distances and the other side has a straight line for heel to toe walking, walking sideways, and walking backwards - great for those home care PT's who travel!

 

  • Cut one a yoga mat for a non skid, easy to clean padded surface! Great for inclines or a large plastic adapted swing!


  • Tall kneeling with knees on rolled up yoga mat with or without feet on ground - add reaching and midline crossing activities to really work on balance! You can also do this in 1/2 kneel with front foot or back knee on rolled up mat!
  • For the little ones, use it as a bolster to have babies straddle and reach down to pick up toys or puzzle pieces for the toddlers!

If you have any more great ideas, please feel free to comment!

DISCLAIMER: "The San Diego Pediatric PT" claims no credit for any images posted on this site unless otherwise noted. Images on this blog are copyright to its respectful owners. If there is an image appearing on this blog that belongs to you and do not wish for it appear on this site, please contact me via e-mail at veronicaglendpt@gmail.com with a link to said image and it will be promptly removed.

Thursday, October 13, 2016

Fun Activities with a Scooter Board!

This is one of my all-time favorite pieces of equipment to use with my kiddos - a scooter board! Mahalo once again to the amazing therapists in Pediatric Physical Therapists Facebook group for all their ideas and to help me compile this list!
  • Sit and use plungers to propel themselves - great for core and arm strength!
  • Slide down ramps on stomach - not only is this super fun, but it's a great way to work on back and leg extension as well!
  • Crawling - place hands on scooter board to focus on lower extremity dissociation
  • Sitting scoot - great to strengthen the hamstrings!

  • Hands or feet on scooter in plank position while sliding in and out - an insane core workout!

 
  • While laying on the scooter board, push feet off wall to propel into bowling pins with head - silly and fun game while strengthening those legs and performing anti-gravity squats!


  • Kneel on scooter and use hands on floor to propel - talk about a core and upper body workout! Can also do this when laying on stomach for more of an isolated upper body workout!

 

  • Scooter soccer - an awesome dynamic core workout!


  • Pulling self on rope while laying on stomach - great for upper trunk extension!


  • Go "Fishing!" Have them scoot to get something, throw them a rope and have them reel themselves in!
  • Tall kneel balance while playing catch or rolling large theraball with them - now that's some great dynamic training!
  • Bridge exercises, placing feet on scooter board for an added challenge!
  • "Inchworms" - place hands on scooter board while standing and "inchworm" their way across the room, pushing the board out as far as they can with their hands then taking small steps back up to their hands.
Comment if you have any more suggestions on fun activities using the scooter board!

DISCLAIMER: "The San Diego Pediatric PT" claims no credit for any images posted on this site unless otherwise noted. Images on this blog are copyright to its respectful owners. If there is an image appearing on this blog that belongs to you and do not wish for it appear on this site, please contact me via e-mail at veronicaglendpt@gmail.com with a link to said image and it will be promptly removed.

Monday, October 10, 2016

Why I Cringe When I See Kiddos Being Swung By Their Arms

We've all seen it before - a happy child being swung around by the arms by their mom or dad. Cute, right? I mean, who doesn't love seeing a giggly little kiddo with a huge smile on their face?

WRONG.

What many people don't know is that this can seriously damage your kiddo's upper extremity and really hurt them!

Radial Head Subluxation, also known as Nursemaid's elbow, is a subluxation (partial dislocation) at the elbow joint when the annular ligament in the elbow joint becomes pinched. Nursemaid's elbow is seen mostly in toddlers (ages 1 to 4 years old), but can be seen in children up to 7 years of age.

 

The elbow joints (humeroulnar, humeroradial, and radioulnar) is composed of 3 bones - the humerus, which is your upper arm; the ulna, which is the pinky side of your forearm, and the radius, which is the thumb side of your forearm, and the bone that is involved with the injury. When there is axial traction of the forearm in the pronated and extended position, this places the radial head in a vulnerable and unstable position, leading to subluxation of the radial head out of the annular ligament. Due to the increasing strength of the annular ligament and size of the radial head, this makes Nursemaid's elbow more uncommon after 7 years old.

After the subluxation, you may not see any noticeable redness or swelling. Most toddlers will not want to move the affected arm and hold it in an adducted, flexed and pronated position. They may complain of pain at the the hand or elbow, but may have a difficult time really pinpointing an area of severe pain. They may not even complain of pain or tenderness when you touch the elbow. 

If you think your child may have suffered a radial head subluxation, do not force them to move their arm, as this may injure the joint even further. Tell your doctors about any details of the possible mechanism of injury. Although the most common mechanism of injury is when the child is picked up by their hands, it can also happen if they pull their hand or arm out of an adult’s hand. 

Your doctor will treat Nursemaid's elbow my manually reducing the subluxation. They may even splint the elbow for a few weeks. Remember that in the first few weeks after the reduction, the chance of reinjury is high, so make sure to manage your kiddo's activities to prevent this from happening again.

So what is the best way to hold your child to prevent this injury? Never lift a kiddo by the arms - period! use both of your hands and lift them from under the arms around the trunk. Make sure you teach other family members and caregivers for your child the same technique and to be careful if their child pulls away from them while holding their hand.


Please share this post to educate other caregivers and spread the word!

References: 
- Skaggs, D., & Pershad, J. (1997). Pediatric elbow trauma. Pediatric emergency care, 13(6), 425-434.
- Nursemaid's Elbow. (1998-2011). Retrieved October 05, 2016, from http://www.nationwidechildrens.org/nursemaids-elbow

DISCLAIMER: "The San Diego Pediatric PT" claims no credit for any images posted on this site unless otherwise noted. Images on this blog are copyright to its respectful owners. If there is an image appearing on this blog that belongs to you and do not wish for it appear on this site, please contact me via e-mail at veronicaglendpt@gmail.com with a link to said image and it will be promptly removed.

Tuesday, October 4, 2016

Fun Activities with a Wedge Mat!

Let's continue with more fun activities! This time, it's with the wedge mat. Mahalo again to the wonderful therapists in the Pediatric Physical Therapists Facebook group for sharing all your creative and awesome ideas!

Babies/Infants/Toddlers:
  • Tummy Time - use to help with weightbearing through the arms or to work on neck extension - good for any age! 
  • Neck flexion - help those kiddos who are still working those neck flexors to get that nice chin tuck for pull to sit! 
  • Sitting balance - promotes weight shifting and core strengthening, especially when paired with upper extremity activities 
  • Rolling - if a kiddo is having difficulty rolling, the wedge mat can be very helpful as a first step to learning how to complete the transfer 
  • Sidelying to sit - the wedge mat makes that initiation of this transfer a little easier and helping against gravity to get up to sitting.
  • Tall kneel - can use wedge mat for arm support, and roll balls down incline for fun! 
School Age:
  • Crawl or bear walk up incline - excellent core workout and challenging endurance! 
  • Walking up - great for kiddos who toe walk! Have them stand and/or walk up the incline with proper heel strike to increase ankle dorsiflexion. 
  • Jumping - small enough to practice jumping off and landing, plus added standing balance on the squishy wedge mat prior to jumping 
  • Walking down - good to improve that quadricep eccentric control 
  • Crunches - extra challenging core exercise! 
  • Long sitting - great for hamstring stretching, use on decline if have tight hamstrings. This position is also good for working on reach forward and throwing for trunk rotation! 
If I missed any, please feel free to comment and add any more activities you can think of to this list!

DISCLAIMER: "The San Diego Pediatric PT" claims no credit for any images posted on this site unless otherwise noted. Images on this blog are copyright to its respectful owners. If there is an image appearing on this blog that belongs to you and do not wish for it appear on this site, please contact me via e-mail at veronicaglendpt@gmail.com with a link to said image and it will be promptly removed.